The Big D

Christopher Hitchens had been a prolific journalist and public intellectual for more than three decades when he finally achieved the global fame he so richly deserved following the publication of God Is Not Great in 2007.

“Hitch” had been a swaggering figure in literary and political circles for many years before this. He was brilliant prose stylist who savaged the reputations of Henry Kissinger, Bill Clinton and Mother Teresa. A formidable speaker and debater, he had the gift of the immediate and apposite retort. He moved to the United States in the 1980s, and it was rumoured that the character of the drunken journalist Peter Fallow, in Tom Wolfe’s Bonfire of the Vanities, was based on him. Charismatic and good-looking in a slightly battered way, he was part of a close-knit coterie of writers which included Martin Amis, Salman Rushdie, Ian McEwan and James Fenton. After the success of God Is Not Great, he joined the premier league of celebrity atheist intellectuals. Richard Dawkins was perceived as arrogant, humourless and hectoring, but even Hitchens’s opponents admired his wit, his preternatural fluency and his cheek. Although wildly inconsistent and self-contradictory, he never confessed to a moment’s doubt.

When, in 2010, he was diagnosed with oesophageal cancer, it came as no great surprise, the major risk factors for the condition being smoking and heavy drinking, both of which Hitchens cheerfully admitted to: “In order to keep reading and writing, I need the junky energy that scotch can provide, and the intense short-term concentration that nicotine can help supply.” Although he managed to quit smoking briefly in 2007, it was too late. “Knowingly burning the candle at both ends and finding that it often gives a lovely light ... I have now succumbed to something so predictable and banal that it bores even me.” His “rackety, bohemian life” finally caught up with him in June 2010 when, during a tour to promote his memoir, Hitch-22, he was taken acutely ill in his hotel bedroom, (“feeling as I were actually shackled to my own corpse”) whisked off to the nearest emergency room and diagnosed with Stage Four oesophageal cancer (“the thing about Stage Four is that there is no such thing as Stage Five”): the cancer had spread, or metastasised, to his lungs and the lymph nodes in his neck. Following this diagnosis, he wrote a number of articles about his illness for Vanity Fair, where he had been a contributor for many years. These articles have been collected, edited and book-ended by moving tributes from his wife, Carol Blue, and his editor, Graydon Carter. This little book is simply called Mortality.

I am intrigued by Mortality for one main reason, which is this: Hitchens’s beliefs about his advanced cancer and its treatment were, for a man whose fame rested on his scepticism, uncharacteristically optimistic. I hesitate to use the word delusional, as he admitted that he would be very lucky to survive, but he clearly steadfastly hoped, right to the end, that his particular case of advanced cancer might lie on the sparsely populated right side of the bell-shaped curve of outcome statistics. He famously mocked religious folk for their faith in supernatural entities and survival of the soul after bodily death, yet the views expressed in Mortality are just as wishful and magical. “The oncology bargain [oncology is that branch of medicine which deals with the treatment of cancer],” writes Hitchens, “is that in return for at least the chance of a few more useful years, you agree to submit to chemotherapy and then, if you are lucky with that, to radiation or even surgery.” Years? I must now confess to a professional interest. I am a gastroenterologist in a large acute hospital, and I have diagnosed many patients with oesophageal cancer. “Years” is a word not generally used when discussing prognosis in Stage Four oesophageal cancer, “months”, in my experience, being a more useful one.

Although bracingly dismissive of the absurd notion of “battling cancer”, he is an ardent admirer of modern American oncology: “For example, I was encouraged to learn of a new ‘immunotherapy protocol’, evolved by Drs Steven Rosenberg and Nicholas Restifo at the National Cancer Institute. Actually, the word ‘encouraged’ is an understatement. I was hugely excited.” He contacts Dr Restifo (I would imagine that American oncologists are keen on celebrity patients), who responds enthusiastically: “Some of this may sound like space-age medicine, but we have treated well over 100 patients with gene-engineered T cells, and have treated over 20 patients with the exact approach that I am suggesting may be applicable to your case.” His hopes are dashed, however, when it turns out that his immune cells do not express a particular molecule (HLA-A2) which must be present for this pioneering treatment to work: “I can’t forget the feeling of flatness that I experienced when I received the news.”

His hopes are raised again when he is emailed by “perhaps fifty friends”, about a television program called 60 Minutes, which “had run a segment about the ‘tissue engineering’, by way of stem cells, of a man with a cancerous esophagus. He had effectively been medically enabled to ‘grow’ a new one.” His friend Francis Collins, molecular biologist and devout Christian, “gently but firmly told me that my cancer had spread too far beyond my esophagus to be treatable by such a means”. Collins evokes ambivalent feelings in Hitchens: “Dr Francis Collins is one of the greatest living Americans. He is the man who brought the Human Genome Project to completion, ahead of time and under budget, and who now directs the National Institutes of Health. He is working now on the amazing healing properties that are latent in stem cells and in “targeted” gene-based treatments. This great humanitarian is also a devotee of the work of C.S. Lewis, and in his book The Language of God has set out the case for making science compatible with faith.”

Ironically, it is the Christian who has to lower the expectations of the sceptical atheist. Hitchens proposes to Collins that his entire DNA, along with that of his tumour, be “sequenced”, “even though its likely efficacy lies at the outer limits of probability”. Indeed. Collins is circumspect, conceding that if such “sequencing” was performed, “it could be clearly determined what mutations were present in the cancer that is causing it to grow. The potential for discovering mutations in the cancer cells that could lead to a new therapeutic idea is uncertain – that is at the very frontier of cancer research right now.” Diplomatically put, Dr Collins. He also points out a more prosaic reason for Hitchens not having his genome “sequenced”, namely that “the cost of having it done is also very steep at the moment”. Although this is not mentioned in Mortality, his tumour DNA was eventually sequenced, and showed a mutation for which a known chemotherapeutic agent already exists, and Hitchens was duly started on this drug.

Hitchens was strongly encouraged in his optimism: “An enormous number of secular and atheist friends have told me encouraging and flattering things like, ‘If anyone can beat this, you can’, ‘Cancer has no chance against someone like you’; ‘We know you can vanquish this.’” More alarmingly, however, his wife and his closest friend, Martin Amis, shared this optimism. Amis, interviewed some months after Hitchens’s death, answered a question about his reasons for moving to New York: “Just over two years ago, my mother died, and within a week, the prognosis for Christopher Hitchens was available. That got us to thinking about mortality and my wife’s mother and step-father. We thought, “They’re not going to be around forever”. At this point, it looked as though Christopher might well live for five or ten years more (my italics) and those two considerations were enough.”

Mortality closes with an “Afterword” by his wife, who writes: “Christopher was aiming to be among the 5 to 20 percent of those who could be cured (the odds depended on what doctor we talked to and how they interpreted the scans).” I wonder how his doctors could have given a man with Stage Four oesophageal cancer such expectations of long-term survival, let alone a one in five chance of cure (which is about the survival chances for all oesophageal cancers, the lucky ones being those with very early, localised disease, not those with metastases in their lungs and lymph nodes). A quick glance at the website of the American Cancer Society would have informed Hitchens that five-year survival for Stage Four oesophageal cancer is 3 per cent (surprisingly high, I thought, as I have never seen a single patient with advanced oesophageal cancer survive five years.) She continues: “Without ever deceiving himself about his medical condition, and without ever allowing me to entertain illusions about his prospects for survival, he responded to every bit of clinical and statistical good news with a radical, childlike hope.”

When Hitchens died at the MD Anderson Cancer Center in Houston, Texas, his wife was clearly not prepared: “The end was unexpected.” In Mortality she describes how Hitchens, still intubated after a bronchoscopy, and therefore unable to speak, scribbled notes for her, such as: “I’m staying here [in Houston] until I’m cured. And then I’m taking our families on a vacation to Bermuda.” Interviewed on Australian television after his death, she said: “Well, first off it was not clear to his doctors or to us that he was dying. His very radical state-of-the art medical treatments had proved quite successful and the cancer was in abeyance ... the oncologist said he was in the one per cent of people who could have been alive then and we hoped that he would either go into a long remission or certainly have quite a bit more time. He caught a very, very virulent pneumonia, a hospital pneumonia, one so powerful that everyone who came to visit in the hospital in the last few days had to wear gowns, masks, gloves and were told it could be spread outside the hospital. So even though he’s been sick for some time and we understood the seriousness of his condition, the ending was quite a shock to him and to me. I don’t think we actually knew that he was gonna die till maybe 20 hours before ...” Asked by her interviewer whether Hitchens considered at that time “it might be the moment to let go?”, Blue answered: “No, not at all, actually, because he’s been given such a prognosis. When they did the follow-up scan basically it was black; no cancer was showing, so ... and as I say, he was ill for quite some time, but the actual ... diagnosis of his very virulent hospital-acquired pneumonia and then ... the course it took over the last few days was quite a surprise so it was almost like, you know, hearing the news that your beloved had been in a car crash. So it was kind of odd. It was not really expected at that moment at all, so that was very, very hard.”

Mortality contains vintage Hitchensian demolitions of such received wisdoms as “battling cancer”: “People don’t have cancer: They are reported to be battling cancer. No well-wisher omits the combative image: You can beat this. It’s even in obituaries for cancer losers, as if one might reasonably say of someone that they died after a long and brave struggle with mortality. You don’t hear it about long-term sufferers from heart disease or kidney failure.” He recalls the absurd quixotic optimism of the Nixon-era “War on Cancer”, when America, fresh from conquering the moon, decided that the “big C” was next. He quotes a wickedly funny line from Updike’s Rabbit Redux, where Mr Angstrom Sr declares: “they’re just about to lick cancer anyway and with these transplants pretty soon they can replace your whole insides”. He is assailed with well-meaning suggestions: “in Tumortown you sometimes feel that you may expire from sheer advice.” He is wonderfully dismissive of “natural” therapies: “I did get a kind note from a Cheyenne-Arapaho friend of mine, saying that everyone she knew who had resorted to tribal remedies had died almost immediately, and suggesting that if I was offered any Native American medicines I should ‘move as fast as possible in the opposite direction’.” A correspondent from an (unnamed) university advises Hitchens to have himself “cryogenically frozen against the day when the magic bullet, or whatever it s, has been devised.” (This particular nonsense is a rather spooky modern echo of the Christian belief in resurrection, a parallel which Hitchens surprisingly fails to spot.) Inevitably, somebody as well-connected as Hitchens will be advised to see the Top Man (or Woman): “Extremely well-informed people also get in touch to insist that there is really only one doctor, or only one clinic.” (A contemporary equivalent to the medieval visitations to holy shrines and relics?) He admits that he did take up this advice: “The citizens of Tumortown are forever assailed with cures and rumors of cures. I actually did take myself to one grand palazzo of a clinic in the richer part of the stricken city, which I will not name because all I got from it was a long and dull exposition of what I already knew ...”

He ponders on the moment of death, and reminds us of what he wrote in Hitch-22: “Before I was diagnosed with esophageal cancer a year and a half ago, I rather jauntily told the readers of my memoirs that when faced with extinction I wanted to be fully conscious and awake, in order to ‘do’ death in the active and not the passive sense. And I do, still, try to nurture that little flame of curiosity and defiance: willing to play out the string to the end and wishing to be spared nothing that properly belongs to a life span.” When the end came, however, Hitchens had the modern cancer death, comatose for the last day or so. There were no Jamesian profundities or Voltairean bons mots.

Mortality contains heart-breaking accounts of the sheer awfulness of cancer: for Hitchens the loss of his voice is the cruellest blow: “Deprivation of the ability to speak is more like an attack of impotence, or the amputation of part of the personality. To a great degree, in public and private I ‘was’ my voice.” We are spared no chemo-related detail: “the pathetic discovery that hair loss extends to the disappearance of the follicles in your nostrils, and thus to the childish and irritating phenomenon of a permanently runny nose.” An admirer of Nietzsche, he come to realise that the dictum “that which doesn’t kill me makes me stronger” is nonsense: “In the brute physical world, and the one encompassed by medicine, there are all too many things that could kill you, don’t kill you, and then leave you considerably weaker.” He introduces the concept of “cancer etiquette”: “my proposed etiquette handbook would impose duties on me as well as upon those who say too much, or too little, in an attempt to cover the inevitable awkwardness in diplomatic relations between Tumortown and its neighbours.” Only a man with Stage Four cancer himself could, with impunity, skewer the sickly sentimentality of the late Randy Pausch’s The Last Lecture. Pausch, a professor of computer science at Carnegie Mellon University, was diagnosed with terminal pancreatic cancer and became an internet sensation after his lecture was posted on YouTube. The lecture, delivered to a standing ovation at his university, was called Really Achieving Your Childhood Dreams, and included such fridge-magnet aphorisms as “we cannot change the cards we are dealt, just how we play the hand”. Hitchens was unmoved: “It ought to be an offense to be excruciating and unfunny in circumstances where your audience is almost morally obliged to enthuse.”

The late philosopher Sidney Hook is Hitchens’s anti-Pausch. Hook, taken seriously ill in old age, “began to reflect on the paradox that ... he was able to avail himself of a historically unprecedented level of care, while at the same time being exposed to a degree of suffering that previous generations might not have been able to afford.” Hook, suffering from heart failure and a stroke, asked his doctor “to discontinue all life-supporting services or show me how to do it”. His doctor denied this request, and Hook survived: “But the stoic philosopher, from the vantage point of continued life, still insisted that he wished he had been permitted to expire. He gave three reasons. Another agonizing stroke could hit him, forcing him to suffer it all over again. His family was being put through a hellish experience. Medical resources were being pointlessly expended.” Hook’s essay “In Defense of Voluntary Euthanasia” is the perfect antidote to Randy Pausch: “Having lived a full and relatively happy life, I would cheerfully accept the chance to be reborn, but certainly not to be reborn again as an infirm octogenarian.” Hook coined the phrase “mattress graves of pain” to describe the suffering of those similarly afflicted, and concluded his piece with a quotation from the Roman Stoic Seneca: “the wise man will live as long as he ought, not as long as he can”.

Clearly, Hitchens did not adopt Hook’s non-interventionist stance. It could be argued that his approach to his cancer treatment was at odds with much that he previously professed to believe (or not believe) in. In God Is Not Great, he coined the withering phrase “the tawdriness of the miraculous”. He summarised the views of David Hume approvingly: “A miracle is a disturbance or interruption in the expected and established course of things. This could involve anything from the sun rising in the west to an animal suddenly bursting into the recitation of verse. Very well, then, free will also involves decision. If you seem to witness such a thing, there are two possibilities. The first is that the laws of nature have been suspended (in your favour). The second is that you are under a misapprehension, or suffering from a delusion. Thus the likelihood of the second must be weighed against the likelihood of the first.” He backs this up with Ambrose Bierce’s definition of “prayer”: “a petition that the laws of nature be suspended in favour of the petitioner; himself confessedly unworthy”. His wife, his friends and his doctors might wish to remind themselves of what Hitchens wrote in God Is Not Great: “Those who offer false consolation are false friends.” In his memoir, Hitch-22, he was scathing of such wishful thinking: “I try to deny myself any illusions or delusions, and I think that this perhaps entitles me to try and deny the same to others, at least as long as they refuse to keep their fantasies to themselves.”

As far back as 1993, Hitchens wrote about biogenetics in Vanity Fair: “One need not be Utopian about biogenetics, which like any other breakthrough can be exploited by the unscrupulous.” When I was a junior research doctor in the late 1980s, my colleagues used to joke that inclusion of the phrase “genetic polymorphism” in the title was enough to get any scientific paper published. Since the 1980s, molecular biology/genetics has been the dominant force in laboratory medicine, and has been lavishly funded by government agencies. There is now, however, a grudging acceptance in the scientific and medical communities that despite all the advances in genetics, including the sequencing of the entire human genome, there have been precious few applications for treatment of cancer and other serious diseases. Steve Jones, Emeritus Professor of Genetics at University College London, admitted as much in 2009, when he wrote: “We thought it [genetic research] was going to change our lives but that has turned out to be a false dawn.” He went on to suggest that too much money had been spent on genetic research and that such scarce funding would be better spent elsewhere. Many took issue with Jones’s nihilism, but most agreed that genetics has not led to the advances we had hoped for. Most common diseases are a complex mixture of genetic and environmental factors, and only a minority of conditions are caused by a single, identifiable gene mutation.

Why did Hitchens harbour such unrealistic expectations? It is clear that his oncologists (he would appear to have consulted several) actively encouraged his misplaced optimism. Oncologists prefer the word “hope” to “delusion”. Over the years, I have witnessed many cancer patients, after protracted (and ultimately futile) therapies, facing death with all the preparedness of Carol Blue and Christopher Hitchens. These patients often experience a sudden deceleration in medical intensity from high-tech, invasive intervention to a side room, the morphine infusion and the chaplaincy service. Oncologists naturally tend to emphasise the positive, concentrating on the good news flashes, such as the “clear” scan. Most doctors will only impart the cold, bare facts when cornered and directly questioned, usually by patients with the necessary medical knowledge. As a profession, we are loath to appear “blunt” and “uncaring”. Giving cancer patients a truthful and realistic prognosis is not done with the intention of taking hope away, but rather to give that person a framework around which they can plan their remaining time and conclude their affairs. My experience, sadly, is that patients and their families for the most part actively resist such an honest engagement.

Even those within oncology, or the “cancer community” as they sometimes call themselves, accept that the current model of cancer care in developed countries has now become unaffordable and unsustainable. The Lancet Oncology Commission (not exactly a cranky fringe group, but a gathering of the great and the good of modern oncology) produced a lengthy report in 2011, a few months before Hitchens died. They pointed the finger squarely at “overutilisation” and “futile care”. “One factor driving over-utilisation in oncology,” says the report, “is time. It is sometimes quicker and easier to discuss a plan of treatment than to discuss why treatment might not be indicated.” Do something is the default setting of modern oncology; indeed, it is the default setting now of all modern medicine. Futility is at the core of the problem: “Many forms of cancer are currently incurable and patients will eventually die from their disease. If we could accurately predict when further disease-directed therapy would be futile, we clearly would want to spare the patient the toxicity and false hope associated with such treatment, as well as the expense.”

One of the root causes of this crisis in cancer care is sentimentality. I am often told by well-meaning family members that their stricken relative is a “fighter”, by which they mean that the known biological statistics appropriate to other, lesser souls, do not apply in this particular case. The psychologist Bruce Charlton has written about the sentimentalising of medicine: “There is a whole school of subjectivist thinking about ageing, disease, death and the other unavoidable biological realities, that downplays the inevitable and the intractable, and instead asserts that for every health problem there ‘must’ be an answer – somewhere, somehow, if only you fight hard enough, shout loud enough, travel far enough – and shell out enough money.” To his credit, Hitchens dismisses this notion of struggle: “… the image of the ardent soldier or revolutionary is the very last one that will occur to you. You feel swamped with passivity and impotence: dissolving like a sugar lump in water.”

Only those faced with such a diagnosis know how they will react. Although the great majority of oncologists I have encountered have been fine, caring doctors, I am an oncology apostate. I hope that my medical knowledge and bitter experience will spare me the delusions of the layman. Perhaps, perhaps not; some medical acquaintances of mine, diagnosed with cancers as advanced as Hitchens’s, harboured hopes as unrealistic as their lay brethren, but mostly, doctors undergo far less treatment for incurable conditions than do lay folk. An American physician, Ken Murray, wrote a piece called “How Doctors Die”, just a few weeks before Christopher Hitchens died in 2011:

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year survival odds – from 5 percent to 15 percent – albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.
It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

We should be wary of mocking beliefs which we do not share. One man’s delusion and folly is another’s “radical, childlike hope”. As news of Hitchens’s cancer diagnosis first became widely known, evangelical Christians speculated on the internet about whether his illness would lead to a religious conversion. In Mortality, Hitchens scoffs at the notion. But in his time of “living dyingly”, he did find a kind of faith. This was not a return to the Anglicanism of his upbringing, or the Judaism of his mother’s family. Hitchens, the arch-mocker, the über-rationalist, the debunker of myth, found solace and consolation in the contemporary rites of genetics and oncology. Reviewing Arguably (Hitchens’s final prose collection), the philosopher John Gray observed: “That Hitchens has the mind of a believer has not been sufficiently appreciated.”

8/04/2013

Seamus O’Mahony is a physician with an interest in medicine and literature. He has written pieces on AJ Cronin, Axel Munthe and Somerset Maugham for a variety of medical journals.